THE FUTURE OF GLOBAL HEALTH STARTS HERE · 1 THE FUTURE OF GLOBAL HEALTH STARTS HERE 7 Creative...
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THE FUTURE OF GLOBAL HEALTH STARTS HERE 7 Creative Approaches to Health Workforce Challenges
Transcript of THE FUTURE OF GLOBAL HEALTH STARTS HERE · 1 THE FUTURE OF GLOBAL HEALTH STARTS HERE 7 Creative...
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THE FUTURE OF GLOBAL HEALTH STARTS HERE
7 Creative Approaches to Health Workforce Challenges
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INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
AFYA ELIMU: Funding.the.Next.Generation.of.Health.Workers.in.Kenya. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
mHERO: Communicating.with.Health.Workers.on.the.Front.Lines.of.Pandemics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
TUTORAT: Building.a.Culture.of.Quality.in.Senegal’s.Primary.Health.Care.Facilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
HOLDING HEALTH WORKERS ACCOUNTABLE: Using.Data.to.Reduce.Absenteeism.in.Uganda. . . . . . . . . . . . . . . . . . . . . . . 16
THE POWER OF STORYTELLING: Advocacy.by.Frontline.Health.Workers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
GETTING CONTRACEPTIVES TO WOMEN WHO NEED THEM: Senegal’s.Informed.Push.Model. . . . . . . . . . . . . . . . . . . . . . .24
HEALTH4ALL: Strengthening.Health.Workers’.Capacity.to.Serve.Key.Populations.with.Stigma-Free.HIV.Services. . . . . . . 28
ACKNOWLEDGMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
TABLE OF CONTENTS
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How.do.we.come.up.with.creative.solutions.to.health.workforce.challenges?.As.these.seven.approaches.designed.
by.IntraHealth.International.show,.there.is.no.set.formula ..They.range.from.developing.and.integrating.exciting.new.
technologies.to.simply.rethinking.old.ways.of.doing.things;.from.catalyzing.public-private.partnerships.for.common.
good.to.harnessing.the.primordial.power.of.human.storytelling ..
And.why.do.we.need.creative.approaches?.These.examples.cover.a.variety.of.reasons:.from.addressing.intractable.
health.systems.challenges.to.responding.to.emerging.threats;.from.advocating.for.high-level.policy.changes.to.bringing.
key.health.care.services.to.the.hardest-to-reach.populations ..
What.these.seven.approaches.do.have.in.common.is.a.focus.on.the.all-important.role.of.health.workers.and.the.systems.
that.support.them.in.improving.the.health.of.people.and.communities ..We.hope.these.examples.will.inform.the.efforts.
of.other.countries.and.organizations.and.inspire.continued.creative.thinking.as.we.work.together.to.strengthen.the.next.
generation.of.health.workers.in.an.ever-changing.and.complex.global.health.landscape .
INTRODUCTION
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AFYA ELIMUFunding the Next Generation of Health Workers in Kenya
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5
OUR INNOVATION
The.Afya.Elimu.Fund.is.a.public-private.partnership.
that.provides.affordable.loans.to.health.professional.
students ..The.fund.was.established.in.2013.as.a.joint.
venture.among.IntraHealth.International,.through.the.
USAID-funded.FUNZOKenya.project.(2012-2017).and.the.
follow-on.Human.Resources.for.Health.Kenya.Mechanism.
(2016-2021);.Kenya’s.Ministry.of.Education.through.the.
Higher.Education.Loans.Board.(HELB);.the.Ministry.of.
Health;.and.the.private.sector ..
Afya.Elimu.is.a.revolving.fund.that.offers.student.loans.
at.a.4%.interest.rate.(compared.to.the.14%.typical.of.
commercial.rates).to.help.Kenyans.pursue.medical.
training ..It.particularly.serves.those.studying.to.become.
nurses,.clinical.officers,.medical.laboratory.technicians,.
pharmaceutical.technologists,.nutritionists,.health.record.
information.officers,.and.public.health.officers—cadres.
that.form.the.bulk.of.the.health.workforce.in.Kenya.and.
are.critical.to.achieving.universal.health.coverage .
Loan.eligibility.criteria.consider.students’.family.income,.
orphaned.status,.gender,.disability.status,.and.county.
of.origin—prioritizing.hardship.and.high.HIV-burden.
counties ..
In.launching.the.venture,.the.Afya.Elimu.Fund.established.
an.oversight.committee.for.governance,.appointed.HELB.
as.fund.manager,.and.defined.a.partnership.framework.
for.fundraising.targets.with.public.and.private.sectors.
aligned.to.corporate.social.responsibility.principles.and.
shared.value ..The.fund.developed.publicity.materials.to.
create.awareness.and.implemented.rigorous.monitoring.
and.evaluation.for.accountability.to.key.partners ..
Resource.mobilization.strategies.and.appropriate.
financial.management.systems.are.in.place.to.raise.funds.
as.well.as.monitor.fund.performance .
By.June.2019,.the.Afya.Elimu.Fund.had.grown.from.
two.to.ten.partners.(three.public,.seven.private);.it.has.
mobilized.US$16 .1.million.(70%.from.the.public.sector.
through.HELB).since.USAID.provided.the.initial.US$1.
million.in.seed.funding ..Private-sector.partners.include.
the.Family.Group.Foundation,.I&M.Bank,.Standard.
Chartered.Bank—Seeing.is.Believing.initiative,.and.the.
Rattansi.Educational.Trust ..In.2017,.Kakamega.County.
became.the.first.county.government.to.invest.in.the.fund.
to.support.local.students.enrolled.in.medical.training.
institutions.countrywide ..Four.other.counties.are.in.the.
process.of.committing.similar.investments .
WHAT WORKED
As.of.June.2019,.22,491.beneficiaries,.more.than.half.of.
them.women,.had.accessed.Afya.Elimu.Fund.loans.to.
cover.their.tuition ..Those.beneficiaries.came.from.all.47.
Kenyan.counties,.with.82%.of.them.from.27.marginalized,.
hard-to-reach.counties.with.high.rates.of.HIV ..By.that.
same.date,.8,245.beneficiaries.had.graduated.and.were.
available.for.employment ..A.quarter.of.them.were.
already.employed.in.public,.private,.and.faith-based.
health.facilities.that.provide.priority.services.for.universal.
health.coverage,.such.as.HIV.testing,.counseling,.
care,.and.treatment;.prevention.of.mother-to-child.
HIV.transmission;.family.planning;.and.laboratory.
investigation ..Employed.Afya.Elimu.Fund.graduates.
have.repaid.loans.amounting.to.US$540,000,.which.will.
support.additional.needy.students—hence.the.fund’s.
journey.toward.sustainability .
One.recipient,.Statius.Osoro.Ondiba.of.Karantini.Village,.
who.initially.didn’t.know.how.he.would.afford.medical.
training,.has.gone.from.earning.his.diploma.in.clinical.
medicine.to.starting.a.clinic.and.employing.other.health.
workers.to.improve.the.quality.of.health.care.in.his.home.
community .
THE PROBLEM
Kenya.has.an.acute.shortage.of.health.workers,.which.seriously.undermines.its.ability.to.achieve.universal.health.
coverage ..Its.health-worker-to-population.ratio.is.1 .3.to.1,000,.while.the.World.Health.Organization.recommends.
at.least.2 .3.to.1,000 .
To.remedy.that.shortage,.Kenya.needs.more.health.workers.graduating.from.health.professional.programs.and.
joining.the.workforce ..However,.42%.of.the.population.lives.below.the.poverty.line.and.college.education.is.
often.a.luxury ..Medical.training.colleges.charge.around.US$4,280.for.a.3 .5-year.diploma.nursing.program,.which.
is.beyond.the.reach.of.most.Kenyans ..Those.who.want.to.serve.often.lack.the.resources.or.have.to.defer.their.
studies.several.times.in.the.training.cycle,.straining.their.ability.to.complete.their.studies.on.schedule ..
Afya Elimu: Funding the Next Generation of Health Workers in Kenya
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WHAT WE LEARNED
Stakeholder.buy-in,.whether.from.the.private.sector.or.
government,.was.critical.in.setting.up.the.Afya.Elimu.
Fund.as.a.workable.venture.for.medical.education.
financing ..
A.technical.working.group.that.spearheads.fund.
implementation.and.an.oversight.committee.chaired.by.
the.Ministry.of.Health.enhance.operational.efficiency,.
prudent.governance,.and.alignment.with.Government.
of.Kenya.priorities.as.a.flagship.initiative.under.Kenya’s.
Vision.2030.development.program.and.the.president’s.
“Big.Four.Agenda,”.which.includes.universal.health.
coverage ..Partnering.with.HELB.proved.a.big.plus,.as.
the.institution.has.a.longstanding.history.of.financing.
higher.education.in.Kenya,.a.legal.mandate.to.recover.
loans.from.recipients,.and.continued.government.funding.
through.the.Exchequer ..
NEXT STEPS AND OPPORTUNITIES FOR REPLICATION AND SCALE-UP
The.Afya.Elimu.Fund.has.developed.a.manual.that.
guides.its.operations,.charts.its.governance.structures,.
and.streamlines.operational.efficiency ..Building.on.this,.
a.strategic.plan.is.under.development.and.scheduled.
to.be.finalized.by.September.2019.to.anchor.the.fund’s.
sustainability.as.well.as.better.position.it.to.continue.
increasing.access.to.medical.education.for.prospective.
health.workers.through.public-private.partnership.
financing .
As.the.Afya.Elimu.Fund.matures,.it.will.explore.new.
frontiers.of.health.worker.education.financing.that.
include.post-basic.training.(higher.diplomas).to.help.
Kenya’s.devolved.health.sector.provide.advanced.
services.through.specialists’.training.for.nurses.and.
clinical.officers.in.reproductive.health/midwifery,.
oncology,.nephrology,.critical.care,.operating.room.care,.
anesthesiology,.pediatrics,.neonatology,.and.more ..The.
goal.is.to.help.build.a.stronger.health.workforce.that.
offers.both.primary.and.specialized.health.care.services.
as.part.of.universal.health.coverage ..
The.Afya.Elimu.Fund.structure.of.public-private.
partnership.financing.provides.a.model.that.other.
countries.can.consider.replicating.to.increase.
educational.access.to.needy.students.who.want.to.
become.health.workers .
2013/14 2014/15 2015/16 2016/17 2017/18
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
20,000
$1,1191,942 $1,831
5,095$5,237
9,330$8,117
12,895$11,719
18,211
2018/19
22,000
24,00022,491
$16,100
Funds mobilized (in thousands USD)
Beneficiaries supported (cumulative)
Figure 1: Growth of fund and beneficiaries, 2013-2019
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For.Beatrice.Mudhai,.the.youngest.child.in.a.family.
of.ten,.money.had.always.been.stretched ..So.much.
so.that.she.had.to.wait.three.years.before.joining.
college ..During.the.gap.years,.Beatrice.conceived.her.
first.child,.Norelle .
“It.was.one.of.the.most.difficult.times.in.my.life,.a.
mixed.bag.of.joy.and.gloom,”.Beatrice.says ..“I.was.
glad.to.be.a.mother,.but.not.ready.to.marry.the.
father.of.my.child,.as.we.were.both.very.young.with.
no.means.to.support.the.child .”
Determined.to.further.her.education,.in.March.2011,.
Beatrice.left.her.young.baby.in.her.mother’s.care.and.
enrolled.at.Mukumu.School.of.Nursing,.Kakamega,.to.
pursue.her.dream—a.diploma.in.nursing .
During.the.course.of.her.program,.Beatrice.struggled.
to.pay.her.fees ..She.was.in.and.out.of.school,.taking.
on.odd.jobs.to.make.ends.meet ..Despite.her.hard.
work,.her.hopes.to.complete.her.studies.were.almost.
dashed.in.2015.as.she.approached.her.final.semester.
with.no.money.to.pay.her.fees ..Having.depleted.her.
family’s.resources,.she.despaired .
Then,.on.an.ordinary.afternoon,.Beatrice.was.
summoned.to.the.college.laboratory.where.she.first.
heard.of.the.Afya.Elimu.Fund ..Her.lecturer.described.
the.program.and.encouraged.the.students.to.apply .
“I.followed.the.presentation.halfheartedly,”.she.says,.
“but.applied.nonetheless .”
Two.months.later,.Beatrice.received.a.call.from.the.
principal.notifying.her.that.her.application.was.
successful ..She.had.been.awarded.a.loan.of.KES.
55,000—the.highest.in.her.cohort .
Now.Beatrice.is.an.accomplished.nurse.working.at.
St ..Monica.Mission.Hospital.in.Kisumu,.in.the.HIV.
Comprehensive.Care.Center .
“I.love.my.job,”.she.says ..“Every.day,.I.get.to.help.
people .”
Beatrice.started.repaying.her.loan.two.months.after.
her.graduation.in.December.2015 .
“I gave my mother my first salary,
so she could bless it,” she says.
(This is a common cultural practice
in Kenya to honor a parent.)
“I then started repaying back the
loan the following month, and I want
to finish paying my loan so I can give
another student a chance to achieve
their dreams.”
Adapted from a post by Ida C. Rob published on
IntraHealth’s VITAL blog on November 9, 2017.
Photo Credit: Ida C. Rob for IntraHealth International
Afya Elimu: Funding the Next Generation of Health Workers in Kenya
REIGNITING A YOUNG MOTHER’S DREAM
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mHEROCommunicating with Health Workers on the Front Lines of Pandemics
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OUR INNOVATION
As.the.world.became.alarmed.about.what.could.
become.a.global.pandemic,.staff.from.IntraHealth.
International.and.UNICEF.brainstormed.ways.to.connect.
with.the.health.workforce.through.an.instant,.two-way.
communication.platform.between.health.workers.and.
health.officials ..IntraHealth.and.UNICEF.raced.against.the.
clock.as.Ebola.spread.through.the.streets.of.Monrovia.
and.the.hills.of.Sierra.Leone ....
Without.the.time.and.resources.normally.required.
to.create.new.technologies,.IntraHealth.decided.to.
build.on.its.open.source.human.resources.information.
system,.iHRIS,.which.helps.ministries.of.health.and.
other.stakeholders.in.more.than.25.countries.to.collect,.
analyze,.and.use.data.on.their.health.workforces .
Fortuitously,.IntraHealth.had.already.been.in.discussions.
with.UNICEF.about.integrating.iHRIS.with.UNICEF’s.
RapidPro.software.so.that.ministries.could.use.their.
employee.data.to.send.targeted.text.messages.(SMS).to.
health.workers ..With.the.urgency.of.the.Ebola.outbreak,.
IntraHealth.and.UNICEF.sped.up.the.timeframe .
The.resulting.platform,.mHero.(mobile.health.worker.
electronic.response.and.outreach),.brings.together.the.
following.open.source.technologies:
• iHRIS:.The.free.suite.of.software.developed.
by.IntraHealth.for.managing.health.workforce.
information.that.supplies.decision-makers.
with.high-quality.data.on.employee.contact.
information,.deployment,.position,.cadre,.skills,.
qualifications,.and.more .
• DHIS2:.The.web-based.health.management.
information.system.with.robust.visualization.
features.supported.by.the.Health.Information.
System.Programme.(HISP).at.the.University.
of.Oslo,.which.helps.governments.and.
organizations.manage.operations,.monitor.
processes,.and.improve.communications .
• RapidPro:.An.open.source.communication.
platform.owned.by.UNICEF.to.send.and.receive.
data.using.basic.mobile.phones,.manage.
complex.workflows,.automate.analysis,.and.
present.data.in.real.time.by.using.texts.to.
monitor.programs,.track.activities,.or.engage.
with.beneficiaries .
mHero.leverages.the.principles.of.OpenHIE,.a.global.
community.of.practice.dedicated.to.improving.the.
health.of.the.underserved.through.open,.collaborative.
development ..The.platform.operates.on.the.basic.
mobile.phones.that.most.health.workers.already.
own—no.smartphones.or.tablets.are.required ..It.is.
compatible.with.any.health.workforce.information.
system.or.communication.software.that.uses.OpenHIE ..
A.distinguishing.feature.of.mHero.is.that.it.allows.health.
workers.to.initiate.direct.contact.with.health.officials—
allowing.data.and.information.to.be.“pushed”.by.health.
workers,.in.addition.to.being.“pulled”.at.the.request.of.
health.officials .
Within.weeks,.IntraHealth,.with.financial.support.from.
UNICEF,.was.able.to.provide.on-the-ground.support.to.
test.the.technology.and.plan.implementation.in.Liberia ..
This.led.to.a.pilot.by.the.Ministry.of.Health.(MOH).in.four.
counties.in.early.December.2014 .
THE PROBLEM
In.August.2014,.the.world’s.largest-ever.outbreak.of.the.Ebola.virus.disease.was.emerging.in.West.Africa ..There.
were.about.2,000.reported.cases.in.Liberia,.Guinea,.and.Sierra.Leone,.and.the.number.was.growing.rapidly ..
Already-weak.health.systems.were.overwhelmed,.and.officials.had.no.instantaneous.way.of.reaching.frontline.
health.workers.with.critical,.lifesaving.information.or.support ..With.each.passing.day,.communications.gaps.
accelerated.the.spread.of.the.virus ..
For.responding.organizations,.health.workers.served.as.critical.eyes.and.ears,.identifying.Ebola.cases.as.they.
emerged ..Tragically,.with.a.risk-of-exposure.rate.up.to.42%.higher.than.the.average.person,.many.fell.ill.or.
abandoned.their.posts ..Compounding.the.crisis,.governments.lacked.a.clear.picture.of.where.health.workers.
were.located.and.what.services.they.were.providing ..To.fight.the.spread.of.Ebola,.they.needed.real-time.
information.on.the.availability,.location,.and.needs.of.their.health.workforce ..Health.workers,.in.turn,.needed.
information.about.how.to.protect.themselves.against.the.virus.and.the.ability.to.share.critical.data.about.the.
disease’s.spread .
mHero: Communicating with Health Workers on the Front Lines of Pandemics
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WHAT WORKED
The.pilot.test.in.Liberia.reached.289.health.workers.
in.four.counties ..The.ministry.used.SMS.exchanges.to.
validate.health.workers’.contact.information,.including.
their.phone.numbers,.job.titles,.supervisor.information,.
and.health.facility.association .
Early.in.the.development.and.testing.phases,.the.ministry.
indicated.it.wanted.mHero.to.be.used.beyond.the.Ebola.
response.to.strengthen.overall.communication.and.the.
country’s.health.system ..Consequently,.other.capabilities.
developed.for.mHero.include.the.ability.to.conduct.
“flash”.surveys,.share.inventory.reports,.send.messages.
regarding.refresher.training.and.courses,.and.inform.new.
employees.about.payroll.IDs .
mHero was deployed to varying
degrees in Guinea and Sierra Leone in
the aftermath of the Ebola response
and has since been implemented in
Mali and Senegal as part of the Global
Health Security Agenda to support
integrated disease surveillance and
response.
IntraHealth.and.UNICEF.worked.with.Liberian.
stakeholders.to.improve.and.scale.mHero.and.build.
institutional.capacity.within.the.ministry.to.guide.and.
manage.the.platform ..In.December.2015,.the.ministry.
formally.integrated.mHero.into.its.Health.Information.
System.(HIS).and.ICT.Strategic.Plan.for.2016-2021,.which.
made.its.use.an.official.part.of.the.government’s.health.
strategy.and.HIS.architecture ..By.January.2018,.more.
than.17,000.health.workers.throughout.Liberia.had.been.
contacted.via.mHero .
WHAT WE LEARNED
There.was.a.significant.learning.curve.with.mHero.in.
Liberia,.starting.with.the.fact.that.many.health.workers.
were.unfamiliar.with.how.SMS.worked,.and.were.afraid.to.
respond.for.fear.of.incurring.charges ..(Due.to.a.UNICEF-
negotiated.short.code.with.mobile.network.operators,.it.
did.not.cost.health.workers.to.send.messages .).Health.
workers.were.not.accustomed.to.receiving.messages.
from.the.ministry.on.their.personal.phones.and.often.
ignored.them ..Simultaneously,.the.ministry.did.not.know.
how.to.respond.to.messages.from.workers ..Additionally,.
the.system.was.only.as.good.as.the.cellular.networks,.
which,.at.the.time,.did.not.cover.30%.of.Liberia’s.
population ..Due.to.overwhelmed.cellular.networks.during.
the.Ebola.crisis,.text.messages.would.sometimes.take.as.
long.as.24.hours.to.arrive,.negating.the.rapid.response.
mHero.promised ..Finally,.the.pilot.revealed.that.some.
of.the.data.and.contact.information.in.iHRIS.was.out.
of.date,.making.it.impossible.to.contact.those.health.
workers ..
While.poor.infrastructure.delayed.mHero.
implementation,.IntraHealth.worked.strategically.with.
other.partners.and.donors.to.improve.infrastructure.in.
Liberia,.Guinea,.and.Sierra.Leone.by.investing.in.basic.
Internet.connections.and.providing.servers.and.backup.
servers.for.data ..IntraHealth.also.worked.with.mHero.
teams.in.the.respective.ministries.to.foster.skills-building.
in.systems.operations.and.data.use .
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NEXT STEPS AND OPPORTUNITIES FOR REPLICATION AND SCALE-UP
Using.OpenHIE’s.open.data.exchange.standards.means.
that.mHero.is.replicable.in.multiple.countries.and.
contexts ..With.funding.from.the.USAID.K4Health.project,.
collaborators.were.able.to.document.mHero’s.capability.
and.modify.it.to.serve.as.an.electronic.integrated.disease.
surveillance.and.response.system .
After.the.phase-out.of.IntraHealth.from.the.Liberia.
mHero.project.in.2018,.additional.funds.were.provided.
for.UNICEF.to.work.with.the.ministry.to.sustain.the.
platform,.as.it.had.become.an.integral.part.of.the.
ministry’s.HIS ..USAID.is.supporting.an.activity.to.
strengthen.mHero.in.Liberia.through.September.2019 ..
The.goals.of.this.activity.are.to.make.mHero.the.go-to.
resource.in.routine.and.emergency.situations,.build.
the.capacity.of.the.ministry.to.use.information.mHero.
gathers.for.informed.decision-making,.and.fully.transition.
the.management.of.mHero.to.the.ministry .
In.2019,.IntraHealth.was.awarded.funding.from.Digital.
Square.for.a.project.called.Zero.to.mHero,.which.will.
enhance.functionalities.and.make.the.platform.easier.
to.deploy ..Other.plans.to.expand.the.capability.of.the.
mHero.platform.include.streamlined.integration.for.
health.worker.contact.information.and.integration.with.
iHRIS.version.5 ...
mHero: Communicating with Health Workers on the Front Lines of Pandemics
12
TUTORATBuilding a Culture of Quality in Senegal’s Primary Health Care Facilities
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13
OUR INNOVATION
IntraHealth’s.experience.has.shown.that.peer.health.
workers.from.the.same.health.districts.often.make.better.
coaches.and.mentors.for.health.workers.than.outside.
experts ..To.test.this.approach.in.Senegal,.IntraHealth,.
with.the.Ministry.of.Health.and.Social.Action,.designed.
and.piloted.Tutorat.(which.means.“mentoring”.in.French).
beginning.in.2008,.drawing.on.IntraHealth’s.Learning.for.
Performance.approach,.which.combines.instructional.
design.and.performance.improvement ..
Mentoring.and.coaching.are.the.foundation.of.Tutorat,.
which.seamlessly.integrates.1).a.rapid.needs.assessment.
to.identify.inefficiencies.and.performance.gaps,.
2).action.planning,.3).tailored.training.materials.to.
address.gaps.in.knowledge.and.skills,.4).overlap.with.
local.supervision.systems,.4).collaboration.with.health.
facility.management,.and.5).facilitywide.performance.
improvement,.while.building.local.ownership.and.a.
sustainable.culture.of.quality ..
Tutorat.differs.from.other.on-the-job.training.and.
performance.improvement.efforts.in.that.it:
•. Focuses.on.the.specific.needs.of.health.workers.
by.taking.a.customized.approach.to.assessing.
performance.gaps,.improving.individual.
performance,.and.addressing.individual.learning.
needs ..Training.is.delivered.onsite.at.health.
facilities,.allowing.health.workers.to.learn.in.
the.same.context—with.the.same.equipment,.
supplies,.clients,.and.colleagues—in.which..
they.work .
•. Minimizes.health.service.disruption ..
•. Emphasizes.a.whole-facility,.whole-system.
approach ..Tutorat.engages.health.workers.and.
support.staff,.managers,.and.the.communities.
being.served ..Through.this.holistic.approach,.
health.workers.gain.skills.while.problems.with.
supplies,.infrastructure,.management,.policies,.
and/or.funding.are.identified.and.prioritized.
for.correction ..Health.committees.composed.of.
community.members.help.hold.health.facilities.
accountable.for.improvements,.mobilize.
resources,.and.devise.solutions .
In.2013,.IntraHealth.introduced.the.expanded.TutoratPlus,.
which.includes.six.mentoring.packages.that.cover.family.
planning,.maternal.health,.disease.management,.facility.
management,.health.information.systems.management,.
and.health.communication.and.(demand).promotion ..
TutoratPlus.also.added.a.facility-level.situation.analysis.
that.examines.infrastructure,.equipment,.and.supplies;.
creates.an.empirical.identification.of.performance.
gaps.by.equipping.mentors.and.regional/district.health.
management.teams.with.tools.to.measure.and.evaluate.
THE PROBLEM
Faced.with.critical.shortages.of.health.workers,.particularly.in.rural.areas,.Senegal.has.struggled.with.unwanted.
pregnancies.and.high.maternal.and.infant.mortality.rates ..Since.2006,.IntraHealth.International.has.led.a.series.
of.USAID-funded.projects.in.Senegal.to.build.the.capacity.of.health.workers.to.offer.high-quality.services.for.
family.planning,.reproductive.health,.and.maternal,.neonatal,.and.child.health .
In.2008,.IntraHealth.began.advocating.to.allow.nurses.and.other.health.workers,.and.not.just.doctors,.to.provide.
long-acting.and.reversible.contraceptives.(LARCs) ..This.proposal.made.sense.in.Senegal,.where.nurses.are.the.
principal.family.planning.service.providers.in.smaller.primary.health.care.facilities.that.serve.the.majority.of.the.
population ..However,.this.type.of.task-sharing—where.procedures.normally.performed.by.higher-qualified.health.
workers.are.undertaken.by.other.health.workers.with.less.formal.training—requires.adequate.skills-building.and.
supervision .
Despite.significant.multiyear.investments.in.traditional.training.approaches.in.Senegal,.their.effectiveness.had.
been.limited.for.several.reasons:.classroom.training.was.largely.theory-based;.health.services.were.interrupted.
while.providers.attended.training;.trainings.were.not.based.on.the.specific.needs.and.context.of.the.health.
workers.and.the.facilities.in.which.they.worked;.and.the.health.facility.environment.did.not.encourage.health.
workers.to.apply.the.new.skills.they.acquired.during.training .
Tutorat: Building a Culture of Quality in Senegal’s Primary Health Care Facilities
14
performance;.and.further.strengthens.engagement.with.
local.officials.and.health.committees.by.creating.district-
level.action.plans.and.evaluating.progress.through..
regular.reviews .
Before.TutoratPlus.was.introduced,.the.Ministry.of.Health.
and.Social.Action.conducted.a.baseline.situation.analysis.
of.1,330.facilities.in.14.regions.to.assess.health.workers’.
family.planning.knowledge.and.skills;.health.facility.
management.and.infrastructure.(e .g .,.availability.of.
running.water,.electricity,.infection.prevention.materials,.
and.IUD.and.implant.insertion.kits);.and.relationships.
with.the.community.to.identify.gaps.contributing.to.
poor.performance ..The.district.action.plans.outlined.
activities.to.address.three.primary.gap.areas:.provider.
performance,.equipment,.and.infrastructure ..
Tutorat.is.now.in.its.third.major.iteration,.Tutorat
3.0,.which.is.now.supported.by.the.USAID-funded.
Neema.project.led.by.IntraHealth ..Tutorat 3.0.is.being.
implemented.in.seven.regions.and.is.designed.to.better.
address.gender.issues.and.incorporate.management.
of.the.community.health.system ..Tutorat 3.0.includes.
six.modules:.management.of.pregnancy,.delivery,.and.
postpartum;.family.planning;.disease.management;.
organization.of.services;.social.and.behavior.change.
communication;.and.community.health.management ..
WHAT WORKED
Senegal.first.piloted.Tutorat.in.six.regions,.training.407.
nurses.and.midwives.at.52.facilities.in.IUD.and.implant.
insertion.and.removal.and.infection.prevention ..Those.
facilities.quickly.started.hitting.their.targets.for.health.
service.improvements ..A.2011.evaluation.showed.a.97%.
satisfaction.level.with.Tutorat.among.health.workers.and.
stakeholders.at.participating.health.centers ..Based.on.
these.results,.the.ministry.committed.to.scaling.up.the.
approach.nationwide.and.Senegal.changed.its.national.
policy.to.allow.trained.nurses.and.midwives.in.rural.
health.posts.to.offer.LARCs—which.previously.could.only.
be.administered.in.health.centers.and.hospitals .
However,.before.TutoratPlus.was.implemented,.an.
analysis.of.290.facilities.that.wanted.to.strengthen.
family.planning.services.revealed.that.fewer.than.half.
(47%).had.a.health.worker.on.staff.who.could.offer.at.
least.one.LARC ..Sixty-four.percent.of.facilities.did.not.
have.implant.kits.in.stock.and.69%.lacked.IUD.kits ..After.
TutoratPlus.interventions.and.community.engagement,.
all.290.facilities.could.provide.LARCs ..
Of.857.health.workers.trained.by.85.mentors.as.part.of.
the.TutoratPlus.intervention.in.those.facilities,.552.were.
clinical.staff.(mainly.nurses.and.midwives).and.305.were.
nonclinical.providers.who.received.mentoring.only.on.
family.planning.counseling.for.new.clients ..The.number.
of.clinical.providers.who.had.an.acceptable.performance.
level.increased.from.32%.to.67%.after.mentoring .
In a subset of 100 facilities for which
comparison data on family planning
service delivery were available, the
number of new clients who received
any family planning method increased
by 64% across the two six-month
periods before and after the TutoratPlus
intervention. The number of new LARC
users increased by 86%, or 1,327 users,
the vast majority of whom chose
implants.
Figure 2: Number of new contraceptive users in 100 facilities, six months before and six months after
TutoratPlus intervention
1,552
6,159
2,879
10,069
Before
After LARCs
Any contraceptive method
15
From.2010.to.2014,.Senegal’s.modern.contraceptive.
prevalence.rate.(mCPR).rose.from.12%.to.20%.among.
women.of.reproductive.age.in.union,.making.as.much.
progress.as.it.had.in.the.previous.20-year.period ..Much.
of.the.increase.occurred.in.rural.areas,.where.the.mCPR.
rose.by.86%.(from.7%.to.13%),.compared.with.a.45%.
increase.in.the.urban.mCPR ..Use.of.LARCs.in.rural.and.
underserved.areas.increased.230%.in.those.four.years,.
from.1 .7%.to.5 .6% .
The.Ministry.of.Health.and.Social.Action,.with.the.
support.of.IntraHealth,.continued.to.scale.up.the.
TutoratPlus.approach ..As.of.2015,.1,330.health.facilities.
were.enrolled.in.the.TutoratPlus.program,.a.level.of.
expansion.made.possible.because.of.the.ministry’s.
strong.support.for.task-sharing.and.decentralizing.LARC.
providers ..For.Tutorat 3.0,.the.Neema.project—which.is.
not.nationwide—focuses.on.611.facilities .
WHAT WE LEARNED
The.sharp.increase.in.the.number.of.women.in.rural.or.
underserved.areas.who.have.requested.LARCs.after.the.
task-sharing.policy.was.instituted.and.health.workers.
were.properly.mentored.via.TutoratPlus.has.revealed.a.
latent.demand.for.those.methods ..
This.approach.highlighted.the.great.value.of.mentors.as.
resources.and.the.need.to.retain.them.within.the.public.
health.system ..Attrition.was.a.major.problem.during.
the.two-year.TutoratPlus.intervention.period,.as.roughly.
half.of.the.mentors.who.were.trained.left.their.facilities.
of.origin ..This.required.training.new.mentors,.and.also.
meant.that.there.were.gaps.in.the.support.available.to.
family.planning.providers.who.offer.LARCs .
NEXT STEPS AND OPPORTUNITIES FOR REPLICATION AND SCALE-UP
Senegalese.health.officials.now.need.minimal.support.
from.IntraHealth.to.manage.the.TutoratPlus.program ..
The.Ministry.of.Health.and.Social.Action.and.IntraHealth.
initiated.a.steering.committee.to.institutionalize.Tutorat.
in.Senegal ..Many.of.the.mentors.have.become.respected.
health.professionals ..District-level.action.plans.continue.
to.prompt.community.stakeholders.to.get.involved.
in.investing.in.and.improving.services.in.their.local.
health.facilities.by,.for.example,.channeling.resources.
toward.staff.recruitment,.expanding.and.improving.
infrastructure,.informing.the.community.about.newly.
available.services,.and.acquiring.new.equipment .
A.more.formal.evaluation.of.the.national.
institutionalization.of.TutoratPlus.in.Senegal.would.
offer.further.insights.to.better.assess.its.potential.for.
replication.in.other.countries ..
Tutorat: Building a Culture of Quality in Senegal’s Primary Health Care Facilities
16
HOLDING HEALTH WORKERS ACCOUNTABLEUsing Data to Reduce Absenteeism in Uganda
16
17
OUR INNOVATION
Tracking.attendance.is.the.first.step.to.ensuring.health.
workers.are.there.to.deliver.critical.services.and.that.staff.
workloads.are.equitable.and.safe ..A.team.of.information.
technology.(IT).and.performance.management.experts.
on.the.IntraHealth-led,.USAID-funded.Strengthening.
Human.Resources.for.Health.(SHRH).activity.piloted.
a.package.of.attendance-tracking.tools,.starting.
with.Amolatar.District.in.January.2016.and.gradually.
expanding.to.other.districts ..
The.backbone.of.the.tracking.system.is.Uganda’s.
unified.Human.Resources.for.Health.Information.System.
(HRHIS),.which.the.Ministry.of.Health.uses.to.collect.data.
to.make.crucial.decisions.about.public-sector.health.
workforce.funding,.deployment,.and.development ..
Uganda’s.HRHIS.is.built.on.the.iHRIS.software,.a.suite.
of.open.source.tools.developed.and.supported.by.
IntraHealth.for.managing.and.planning.the.health.
workforce .
Ever.since.the.pilot.initiative,.facilities.have.been.tracking.
attendance.on.a.daily.basis ..They.enter.it.monthly.into.
HRHIS.and.share.it.with.the.respective.district.health.
officers.and.the.District.Service.Commission .
Once.the.monthly.data.are.in,.payroll.managers.in.each.
district.run.attendance.reports.and.immediately.see.
who.reported.to.work.fewer.than.the.standard.number.
of.required.days.per.month.(usually.20).or.who.arrived.
late ..The.payroll.managers.check.with.facility.heads.
to.see.if.there.are.legitimate.reasons.for.absenteeism,.
such.as.sickness.or.transportation.problems,.before.
recommending.sanctions.to.the.district.health.officer.
and.chief.administrative.officer,.who.oversee.public.
health.facilities ..Sanctions.include.paying.prorated.
salaries.based.on.the.number.of.days.absent,.disciplining.
chronically.absent.staff,.and.removing.“ghost”.workers.
from.district.payrolls .
Most.health.centers.manually.record.attendance,.but.
seven.high-volume.sites,.mostly.hospitals.that.employ.
hundreds.of.health.workers,.began.using.biometric.
scanners.to.log.employees.in.and.out ..
IntraHealth’s.SHRH.team.also.conducted.annual.
longitudinal.analyses.of.health.worker.absenteeism.rates.
in.sampled.districts.and.health.facilities.from.2015.to.
2018 ..Survey.teams.made.unannounced.visits.to.health.
facilities.and.recorded.whether.they.found.workers.
on.the.job.that.day ..They.also.looked.to.see.if.workers.
had.been.on.the.job.during.the.previous.five.working.
days ..The.teams.collected.additional.information.from.
interviews.with.health.managers.at.facility.and.district.
levels ..Absenteeism.was.defined.as.the.number.of.health.
workers.who.are.not.off-duty.who.are.absent.from.the.
health.facility.during.an.unannounced.visit.and.during.
the.previous.five.working.days ..The.teams.also.analyzed.
unauthorized.absenteeism.to.better.understand.the.
problem,.underlying.causes,.and.effective.strategies.to.
address.it .
WHAT WORKED
The.attendance.tracking.tools.led.to.immediate.results ..
Once.employees.realized.they.were.being.monitored,.
unapproved.absences.fell.significantly.in.just.a.few.
months ..During.2015-2018,.overall.health.worker.
absenteeism.(with.and.without.approval).fell.from.69%.
to.41% .
THE PROBLEM
Health.worker.absenteeism.undermines.staff.morale.and.the.quality.of.care.patients.receive ..It.wastes.health-
sector.resources.and.has.even.been.linked.to.patient.deaths .
In.Uganda,.which.has.a.severe.shortage.of.health.workers,.a.2015.study.by.IntraHealth.International.revealed.
that.68 .8%.of.health.workers.in.the.public.sector.either.weren’t.showing.up.or.were.leaving.work.early.so.they.
could.collect.a.second.paycheck.at.a.different.health.site.or.job ..This.put.pressure.on.other.health.workers,.who.
were.already.thinly.stretched,.to.do.more.than.their.share.of.work ..In.worst-case.scenarios,.people.would.arrive.
in.some.Ugandan.health.centers.and.find.that.there.was.no.one.on.staff,.because.everyone.had.decided.to.take.
unauthorized.holidays .
Absenteeism.was.exceptionally.high.among.night-.or.weekend-shift.workers.due.to.lack.of.supervision.at.their.
facilities,.often.forcing.patients.who.could.afford.it.to.pay.for.private.duty.services ..In.Amolatar.District.in.2012,.
clients.who.couldn’t.get.care.at.a.health.center.rioted.and.stormed.the.office.of.the.resident.district.commissioner .
Holding Health Workers Accountable: Using Data to Reduce Absenteeism in Uganda
18
The.success.of.the.pilot.initiative.prompted.the.Ministry.
of.Health.to.ask.the.team.to.roll.out.the.approach.
to.4,507.facilities.in.all.of.Uganda’s.122.districts.by.
August.2018,.and.soon.absenteeism.without.approval.
was.down.to.11 .1%.in.432.sampled.health.facilities ..The.
monitoring.system.allowed.Ugandan.health.officials.to.
comprehensively.track.and.analyze.attendance.data.and.
take.appropriate.actions.against.chronically.absent.staff ..
By.mid-2018,.informatics.developers.at.IntraHealth.had.
begun.encouraging.facilities.to.use.biometric.machines.
that.scan.thumbprints.of.each.and.every.medical.worker.
and.register.time.of.arrival.and.departure ..This.eliminates.
any.chance.of.a.health.worker.gaming.the.system.by.
signing.in.for.a.workmate,.as.fingerprints.are.unique.
to.each.individual.and.require.staff.members.to.be.
physically.present.to.sign.in.or.out ..By.the.end.of.that.
year,.all.14.regional.referral.hospitals.and.14.health.center.
IVs.(minihospitals,.each.serving.a.population.of.roughly.
100,000).in.Gombe,.Adjumani,.Kalanga,.and.Katakwi.
districts.had.added.biometric.systems.to.monitor.
employees ..
The.Office.of.the.Prime.Minister.is.helping.add.biometric.
systems.to.37.district.hospitals.and.health.center.IVs.in.
22.districts.in.eastern.Uganda ..Another.173.of.the.smaller.
health.center.IIIs.(subcounty-level.clinics.with.maternity.
wards).and.IIs.(parish-level.facilities.that.treat.common.
diseases.and.offer.antenatal.care).in.the.same.districts.
received.mobile.phones.to.capture.attendance ..The.
phones.work.in.the.same.way.as.the.biometric.machines,.
but.don’t.require.reliable.electricity ..
Today,.the.district.of.Amolator,.where.the.pilot.project.
began,.is.known.to.have.some.of.the.best.medical.
personnel.in.the.country ..The.HRHIS.monthly.report.put.
absenteeism.in.Amolatar.at.only.3 .2%.as.of.May.2018 .
WHAT WE LEARNED
Governments.can.effectively.reduce.absenteeism.rates.
through.regular.tracking.and.analysis.of.data.using.
technology-based.tools ..However,.fully.addressing.the.
issue.of.absenteeism.requires.a.holistic.and.multipronged.
strategy.that.employs.different.management.
interventions.beyond.a.tracking.system,.such.as.involving.
key.stakeholders,.creating.supportive.supervision,.and.
using.appropriate.rewards.and.sanctions ..A.supportive.
environment.increases.buy-in.and.participation.from.
health.workers ...
The.tracking.tools.revealed.systems-related.causes.for.
absenteeism.in.Uganda,.including.weak.supervision,.a.
lack.of.clear.job.expectations,.delays.in.getting.paid,.
and.poor.working.conditions ..Data.collected.helped.
create.appropriate.sanctions.or.rewards.to.improve.
performance,.retention,.and.health.care.delivery ..District.
authorities.can.also.better.identify.workers.who.are.due.
to.retire.and.determine.where.recruitment.efforts.are.
needed ..
This.program.faced.substantial.hurdles,.beginning.
with.inadequate.IT.infrastructure,.including.computers,.
Internet,.and.inconsistent.electrical.power.at.health.
facilities ..Health.facilities.often.did.not.comply.with.
taking.attendance,.resulting.in.low.or.delayed.reporting.
of.data ..The.system.is.only.as.good.as.the.data.that.
are.shared ..If.managers.don’t.use.the.data.to.promote.
health.worker.productivity,.no.gains.are.made.in.service.
delivery .
The.system.is.still.mostly.manual.and.some.
administrators.at.the.ministry.found.it.difficult.to.
digitize.paper.records ..Workers.who.arrive.late.have.to.
track.down.data.collectors.when.attendance.books.are.
removed,.taking.valuable.time.away.from.other.tasks ..
The.continued.reliance.on.a.paper-based.system.in.many.
facilities.makes.tracking.more.easily.compromised.as.it.is.
still.relatively.easy.for.one.person.to.sign.in.on.behalf.of.
another .
NEXT STEPS AND OPPORTUNITIES FOR REPLICATION AND SCALE-UP
Future.plans.call.for.rolling.out.biometric.tracking.to.
more.districts.to.replace.the.paper-based.systems.and.
to.link.HRHIS,.including.the.attendance-tracking.system,.
with.the.open.source.District.Health.Information.System.
(DHIS2).to.better.assess.health.worker.productivity ..An.
estimation.of.the.financial.cost.of.absenteeism.to.the.
health.system.is.in.progress ..
19Holding Health Workers Accountable: Using Data to Reduce Absenteeism in Uganda
2016 2017 20182015
68.8%
46%42.6% 41.4%
50%
13.7%11.9% 11.1% Absence without
approval
Absence with orwithout approval
Figure 3: Health worker absenteeism, 2015-2018
20
THE POWER OF STORYTELLINGAdvocacy by Frontline Health Workers
20
21
OUR INNOVATION
Storytelling.is.a.way.to.give.a.face.and.narrative.to.
numbers.and.statistics ..Proper.storytelling.can.foster.
empathy,.establish.trust,.and.more.urgently.convey.the.
importance.of.taking.action ..Health.workers.who.can.
provide.first-hand.context.and.succinctly.convey.a.vivid.
portrait.of.the.urgency.and.often.tragic.consequences.of.
the.lack.of.access.to.essential.health.services.are.more.
likely.to.resonate.with.decision-makers ..In.doing.so,.they.
can.influence.policies.to.enhance.health.services.in.their.
communities.and.raise.the.profiles.of.frontline.health.
workers.and.the.structural.barriers.they.face ..
In.2017,.with.support.from.the.Medtronic.Foundation,.
IntraHealth.International.invited.a.handful.of.inspiring.
frontline.health.workers.who.focus.on.fighting.
noncommunicable.diseases.to.participate.in.a.few.
months.of.intensive.storytelling.training ..Since.then,.
IntraHealth.has.trained.12.frontline.health.workers.from.
Brazil,.India,.Ireland,.Liberia,.South.Africa,.Uganda,.and.
the.United.States.in.the.art.of.storytelling.to.better.share.
their.experiences.of.providing.health.care.to.underserved.
communities ..Their.stories.have.been.shared.at.forums.
such.as.the.World.Health.Assembly,.US.congressional.
briefings,.the.Fourth.Global.Forum.on.Human.Resources.
for.Health,.the.UN.Commission.on.the.Status.of.Women,.
the.Global.Conference.on.Primary.Health.Care,.and.
IntraHealth’s.annual.SwitchPoint.conference ..
IntraHealth.and.Medtronic.partnered.on.the.storytelling.
initiative.with.three.principal.aims:.1).to.ensure.global.
health.policymakers.and.influencers.hear.more.voices.
of.frontline.health.workers,.2).that.frontline.health.
workers.who.received.the.training.have.the.tools.to.
continue.advocating.for.policies.and.investments.they.
feel.are.important,.and.3).that.more.organizations.and.
institutions.prioritize.the.voices.and.stories.of.frontline.
health.workers.in.high-level.global.health.policy.forums.
and.meetings .
WHAT WORKED
The.storytelling.training.equipped.health.workers.
to.confidently.and.skillfully.convey.their.stories.and.
use.them.to.try.and.improve.policy.whenever.they.
get.in.front.of.policymakers.and.influencers ..Through.
storytelling,.some.frontline.health.workers.have.
influenced.key.policy.changes ..For.example,.Samalie.
Kitooleko,.a.nurse.at.the.Uganda.Heart.Institute.in.
Kampala,.who.spoke.at.the.World.Health.Assembly.in.
Geneva.in.2017,.spurred.policies.that.allow.all.patients,.
regardless.of.their.ability.to.pay,.to.receive.care.at.the.
institute .
Shortly.after.Maria.Valenzuela,.a.community.health.
worker.from.Arizona,.spoke.in.2017.at.a.congressional.
briefing.organized.by.the.Frontline.Health.Workers.
Coalition.on.the.impact.of.frontline.health.workers,.
bipartisan.House.Resolution.342.was.introduced.in.the.
United.States.Congress ..It.recognizes.that.frontline.
health.workers.are.essential.“to.strengthening.the.
United.States.national.security.and.economic.prosperity,.
sustaining.and.expanding.progress.on.global.health,.and.
saving.the.lives.of.millions.of.women,.men,.and.children.
around.the.world .”.
At.the.2017.World.Health.Assembly,.said.IntraHealth.
president.and.CEO.Pape.Gaye,.“we.saw.the.faces.of.
policymakers.at.the.highest.levels—from.ministers.to.the.
heads.of.multilateral.agencies—transfixed.by.the.stories.
of.these.frontline.health.workers….We.are.proud.to.help.
amplify.their.voices.and.will.keep.pushing.to.ensure.they.
have.a.platform.to.tell.their.stories .”.
Sunil.Kumar,.who.managed.community.health.workers.
for.IntraHealth.in.India’s.Jharkhand.state,.spoke.in.vivid.
detail.about.the.dedication.of.frontline.health.workers.
to.saving.women’s.and.children’s.lives.at.a.World.Health.
Assembly.side.session.that.included.leaders.such.as.the.
director-general.of.the.WHO.and.executive.director.of.
THE PROBLEM
Most.people.become.inured.to.numbers.and.statistics ..When.they.hear.that,.according.to.the.World.Health.
Organization.(WHO),.400.million.people.around.the.world.lack.access.to.essential.health.services,.or.that.the.
world.will.be.short.18.million.health.workers.by.2030,.they.might.have.a.hard.time.comprehending.what.those.
figures.really.mean ..What.exactly.does.a.shortage.of.18.million.health.workers.look.like?.
Statistics,.particularly.those.that.involve.people,.simply.can’t.convey.all.the.complexity.and.humanity.that.
exist.behind.the.numbers ..Sheer.numbers.can.numb ..Data.can.support.the.bones.of.an.argument,.but.human.
experience.fleshes.it.out .
The Power of Storytelling: Advocacy by Frontline Health Workers
22
UNAIDS ..This.helped.spur.WHO’s.first-ever.guidelines.on.
community.health.worker.programs .
Vince.Blaser,.director.of.the.Frontline.Health.Workers.
Coalition,.explained,.“When.we.as.advocates.speak.to.
policymakers.about.the.acute.necessity.of.far.greater.
and.more.strategic.investment.in.the.global.frontline.
health.workforce,.heads.often.nod.but.action.doesn’t.
always.follow ..But.when.policymakers.are.presented.with.
data.combined.with.the.human.stories.that.bring.home.
the.realities.of.working.on.the.front.lines.of.care,.the.
onus.to.act.becomes.much.harder.to.ignore .”
Since the inception of the program,
trained storytellers have been
regularly asked to participate in
panels, leadership programs, or
other opportunities. For example,
Valenzuela was selected to speak on
a plenary at the invitation-only Global
Conference on Primary Health Care in
Astana, Kazakhstan, in October 2018,
and subsequently was selected as an
Aspen-Aetna Healthy Communities
Fellow. Organizations such as Last Mile
Health, Women in Global Health, Global
Citizen, and the Global Health Council
have sought lessons learned from this
initiative or invited storytellers trained
by the project to speak on panels.
23
WHAT WE LEARNED
This.initiative.provided.countless.reminders.of.just.how.
powerful.individuals—and.their.personal.stories—can.be ..
Storytelling,.or.the.ability.to.spin.a.narrative,.is.an.art.
that.is.not.always.intuitive ..By.teaching.health.workers.
how.to.structure.and.present.their.personal.stories,.
helping.them.tap.into.their.authentic.experiences.and.
drawing.out.their.passions,.they.can.gain.the.confidence.
and.authority.that.helps.them.become.agents.for.
change ..
Valenzuela’s.story.of.growing.up.poor.in.the.foster.care.
system.and.becoming.inspired.to.dedicate.her.life.to.
a.community.health.career,.which.she.shared.in.front.
of.nearly.70.congressional.staffers.and.government.
officials,.moved.many.to.tears.and.prompted.them.to.
take.action ..She.was.able.to.get.her.audience.to.imagine.
themselves.as.the.young.child.bouncing.helplessly.from.
foster.home.to.foster.home,.or.as.the.young.woman.
who.received.community.nutrition.classes.and.chose.
to.become.a.social.worker.rather.than.succumb.to.the.
negative.influences.around.her ..
It’s.not.only.policymakers.who.need.to.hear.stories—
patients.also.need.them.to.influence.changes.in.lifestyle.
patterns.or.to.be.encouraged.to.pursue.or.persevere.
with.medical.treatments ..Kitooleko.related.a.story.
about.a.family.who.refused.life-saving.procedures.to.
encourage.another.family.to.seek.treatment.for.their.
daughter ..Within.the.community.of.frontline.health.
workers,.sharing.stories.and.experiences.can.help.inspire.
and.motivate.colleagues,.or.rekindle.a.commitment.to.
serving.others ..Part.of.cultivating.the.art.of.storytelling.in.
health.workers.is.training.them.to.be.attuned.to.others’.
stories.and.how.to.share.those.stories.with.the.larger.
world .
NEXT STEPS AND OPPORTUNITIES FOR REPLICATION AND SCALE-UP
Going.forward,.IntraHealth.and.the.Medtronic.Foundation.
intend.to.train.additional.health.workers.as.storytellers,.
as.well.as.create.a.community.of.practice.for.frontline.
health.workers.to.share.best.practices,.collaborate.on.
advocacy.initiatives,.and.help.inspire.further.storytelling ..
Former.trainees.such.as.Vânia.Soares.de.Oliveira.e.
Almeida.Pinto,.a.community.physician.in.Brazil,.have.
started.regular.storytelling.sessions.among.local.health.
workers ..Ultimately,.IntraHealth.and.Medtronic.hope.to.
have.built.the.foundation.of.a.sustainable.movement.for.
frontline.health.worker.storytelling.for.advocacy .
The Power of Storytelling: Advocacy by Frontline Health Workers
24
GETTING CONTRACEPTIVES TO WOMEN WHO NEED THEMSenegal’s Informed Push Model
24
25
THE PROBLEMIn.2012,.the.Government.of.Senegal.committed.to.more.than.double.its.modern.contraceptive.prevalence.rate.
(mCPR),.which.was.a.little.above.20%,.to.45%.by.2020,.recognizing.that.reliable.access.to.family.planning.would.
also.contribute.to.reducing.the.country’s.high.maternal.mortality.rate ..However,.public.health.facilities,.where.
most.consumers.obtain.contraceptives,.reported.shortages.in.inventory,.or.stockouts,.more.than.a.quarter.of.the.
time .
These.facilities.traditionally.had.to.resupply.their.inventories.using.a.paper-based.“pull”.system.that.left.gaps.in.
stocks ..The.National.Supply.Pharmacy.(PNA).delivered.commodities.to.its.11.regional.supply.pharmacies.from.its.
central.warehouse.in.Dakar.but.had.no.oversight.on.the.last-mile.delivery.to.health.facilities ..Facility.staff.had.to.
travel.to.district.warehouses.to.purchase.contraceptives.and.other.medical.commodities.and.bring.them.back.
to.their.clinics ..With.this.old.distribution.model,.there.was.no.harmony.between.clinics’.needs.and.the.district.
warehouses,.making.it.common.for.products.to.be.in.stock.at.the.national.level.but.absent.from.the.shelves.of.
facilities ..
Another.drawback.of.the.pull-based.inventory.system.was.that.clinic.health.workers,.who.typically.aren’t.
trained.in.supply.chain.management.and.who.have.competing.demands.on.their.time,.were.also.asked.to.track.
and.forecast.needs.for.commodities ..Clinics.were.required.to.pay.for.health.products.up-front.using.their.own.
working.capital,.which.created.incentives.for.some.facilities.to.prioritize.stocking.commodities.that.earned.
higher.margins,.making.family.planning.products,.which.typically.do.not.earn.high.revenues,.a.low.priority ..
OUR INNOVATION
In.2012,.Senegal’s.Ministry.of.Health.and.Social.
Action.and.the.PNA.began.working.with.IntraHealth.
International,.Merck.for.Mothers,.and.the.Bill.&.Melinda.
Gates.Foundation.to.develop.a.nationwide.Informed.
Push.Model.(IPM),.a.supply.distribution.approach.that.
relies.on.private,.third-party.logistics.providers.(3PLs).to.
capture.real-time.data.to.proactively.predict.and.manage.
stock.at.the.facility.level ..
Logisticians.make.monthly.deliveries.of.health.products.
directly.to.facilities,.where.they.evaluate.current.stock.
and.enter.data.into.a.tablet-based.electronic.logistics.
management.information.system.(Dimagi’s.CommCare),.
or.eLMIS,.to.track.consumption.trends.and.forecast.
future.needs ..The.logistics.team.generally.consists.
of.a.driver,.a.logistician,.and.sometimes.an.assistant.
logistician,.trained.in.IPM.technical.procedures .
The.instant.transfer.of.data.from.districts.and.regions.
helps.ensure.that.information.captured.from.facilities.
aligns.with.that.recorded.at.the.national.level.and.can.
be.used.to.regularly.report.on.trends.and.track.progress.
toward.global.and.national.targets ..
The.financial.model.was.also.changed ..Facilities.no.
longer.purchase.supplies.up-front.and.are.charged,.using.
a.consignment.model,.only.for.commodities.consumed.
during.the.preceding.month,.which.enables.them.to.
stock.a.wider.array.of.products ..Facilities.pay.a.25%.
margin.redistribution,.or.percentage.of.net.proceeds.of.
sales,.to.PNA.to.cover.sustainability.of.IPM .
The.pilot.phase.of.IPM.was.introduced.in.2014,.and.the.
ministry.decided.to.scale.the.model.nationally.starting.in.
2015 ..It.now.covers.1,460.facilities.in.all.14.regions.of.the.
country ...
WHAT WORKED
Moving.from.paper.to.the.eLMIS.enabled.stronger.
forecasting.and.tracking ..Logisticians.could.now.use.
historical.data.to.estimate.the.amount.of.product.each.
clinic.needed.and.could.adjust.this.amount.based.on.
a.number.of.variables,.including.climate.conditions,.
fluctuations.in.nationwide.health.trends,.and.regional.or.
local.factors ..In.one.instance,.the.data.allowed.a.district.
to.see.that.declines.in.implant.insertions.were.linked.to.a.
shortage.of.local.anesthetic .
The.pilot.phase.of.IPM.increased.the.use.of.modern.
contraceptives.by.more.than.90%.in.some.regions,.
influencing.the.ministry’s.decision.to.scale.the.model.
nationally ..Areas.that.were.still.experiencing.stockouts.
attributed.them.mostly.to.unexpected.spikes.in.
consumption ..Other.shortages.were.linked.to.logistician.
errors,.nonpayment.from.facilities,.or.contraceptive.
community.outreach.programs.that.spurred.demand.that.
was.not.communicated.to.logisticians ..
Getting Contraceptives to Women Who Need Them: Senegal’s Informed Push Model
26
By.2016,.the.unmet.need.for.contraceptives.had.
dropped.from.88%.to.53% ..Nationwide.consumption.
of.contraceptives.increased.by.48%.over.the.14-month.
period.from.April.2015.to.May.2016.after.full.IPM.
scale-up ..The.ministry.and.PNA.expanded.IPM.to.include.
other.essential.commodities.beyond.contraception,.
as.part.of.a.broader.supply.chain.transformation,.and.
rebranded.the.program.as.Yeksi.Naa.(“I.have.arrived”.in.
Wolof) .
By 2017, Yeksi Naa was able to
consistently deliver over 100 essential
health products to facilities around the
country. That same year, it reduced
contraceptive stockouts to an average
of 2% of all health facilities nationwide,
improving access to family planning
for an estimated 3.2 million women.
Consumption data from all health
facilities is captured electronically
and available for procurement and
programmatic decision-making. Margin
redistribution is estimated to cover 70%
of the costs of administering Yeksi Naa.
Yeksi.Naa.has.transformed.the.delivery.of.essential.
health.products.in.Senegal ..Health.workers.can.remain.
at.their.facilities.rather.than.having.to.travel.to.procure.
supplies ..Clinics.can.be.open.longer.and,.when.patients.
arrive,.the.commodities.they.need.are.much.more.
likely.to.be.in.stock ..The.willingness.of.public-sector.
health.facilities.to.partner.with.private-sector.trained.
logisticians.has.reduced.inefficiency.and.improved.data.
quality.by.ensuring.that.those.responsible.for.recording.
stock.information.and.forecasting.have.the.necessary.
expertise.to.complete.those.tasks ...As.communities.see.
the.value.of.a.consistent.supply.chain,.they.are.more.
willing.to.visit.facilities.for.services.and.supplies.and.
facilities.are.in.turn.more.invested.in.contributing.margin.
redistribution.to.PNA.to.support.Yeksi.Naa .
WHAT WE LEARNED
The.performance-based.contract.competitive.bidding.
process.used.to.select.third-party.logistics.providers.
helps.drive.cost-effectiveness.and.quality.control ..If.
certain.conditions.are.not.met—if,.for.example,.stock-out.
rates.exceed.2%.of.facilities,.based.on.data.from.the.
eLMIS—PNA.can.penalize.the.3PL.financially.or.even.
replace.the.3PL.with.another.company ..This.gives.
3PLs.an.incentive.to.maintain.high.service.levels.at.a.
competitive.cost.and.develop.innovative.solutions.to.
increase.efficiencies ..Beyond.supply.chain.strengthening,.
utilizing.3PLs.drives.local.business.development,.which.
enhances.the.local.economy.and.creates.jobs .
The.final.step.in.Yeksi.Naa’s.success.is.institutionalization.
to.ensure.that.the.program.will.thrive.without.outside.
funding ..While.a.transition.road.map.including.
prerequisite.activities.for.PNA.to.operate.the.program.
was.in.place,.it.was.particularly.important.to.have.strong.
advocacy.from.high-level.government.officials.at.an.
early.stage.of.implementation.and.their.commitment.
to.expend.additional.resources.to.maintain.essential.
activities.over.the.long.term ..Unfortunately,.this.did.not.
occur.in.a.timely.manner,.and,.consequently,.efforts.to.
institutionalize.the.model.did.not.really.start.until.the.
end.of.the.expansion.stage ..By.then,.the.initial.project’s.
remaining.time.proved.too.short.to.institutionalize.IPM.
and.the.project.was.extended.twice,.adding.an.additional.
23.months.to.its.timeline ..
To.catalyze.high-level.support,.the.Yeksi.Naa.team.
deployed.an.intense.advocacy.and.communication.
campaign,.including.certification.ceremonies.in.regional.
capital.cities,.which.were.used.to.attract.media.coverage;.
advocacy.workshops.in.all.14.regions;.and.consistent,.
direct.dialogue.with.the.Minister.of.Health.and.other.
decision-makers ..Senegal’s.former.Minister.of.Health,.
Awa.Marie.Coll-Seck,.publicly.advocated.for.supply.
chain.reform.and.committed.to.making.requisite.policy.
changes ..Senegal’s.President.Macky.Sall.highlighted.his.
commitment.to.the.Yeksi.Naa.supply.chain.model.in.his.
2017.New.Year’s.address.to.the.nation ..
27
NEXT STEPS AND OPPORTUNITIES FOR ADAPTATION AND SCALE-UP
The.Yeksi.Naa.model.has.the.potential.for.adaptation.
and.adoption.elsewhere,.particularly.in.the.West.African.
context.where.supply.chain.systems.are.similar ..Best.
practice.elements.of.the.approach.can.be.applied.
individually.to.supply.chain.systems.in.other.low-.and.
middle-income.countries.to.improve.availability.of.
products.in.health.facilities .
IntraHealth.played.an.important.supportive.role.in.
leading.the.successful.introduction.of.IPM-Yeksi.Naa ..
In.addition.to.helping.develop.and.refine.the.model,.
IntraHealth.provided.extensive.coaching.and.mentorship.
support.to.logisticians.and.relevant.supply.chain.actors.
to.ensure.operational.efficiency ..The.architecture.and.
cost.of.this.support.should.not.be.overlooked.as.other.
countries.consider.adapting.similar.approaches ..As.of.
this.writing,.IntraHealth.is.progressively.withdrawing.
from.high-performing.regions.in.favor.of.those.that.need.
more.intensive.coaching .
Getting Contraceptives to Women Who Need Them: Senegal’s Informed Push Model
Figure 4: Contraceptive consumption rates before and
after IPM implementation in 14 regions of Senegal, all
methods combined (2013-2016)
First 3 regions Next 5 regions All 14 regions
After IPMBefore IPM
91% increase in559 facilities(35 months)
118% increase in447 facilities(26 months)
48% increase in1,394 facilities(14 months)
28
HEALTH4ALLStrengthening Health Workers’ Capacity to Serve Key Populations with Stigma-Free HIV Services
28
29
THE PROBLEM
Globally,.remarkable.progress.has.been.made.in.halting.and.reversing.the.HIV.epidemic:.annual.new.infections.
have.declined.by.35%.since.2000,.and.15.million.people.living.with.HIV.are.now.on.antiretroviral.therapy.
(ART) ..However,.up.to.half.of.all.new.HIV.infections.among.adults.worldwide.occur.among.key.populations:.
sex.workers,.men.who.have.sex.with.men,.transgender.people,.and.people.who.inject.drugs ..As.governments,.
donors,.and.the.wider.health.and.development.community.work.toward.an.AIDS-free.generation,.HIV.programs.
are.better.engaging.with.and.implementing.approaches.that.meet.the.needs.of.key.populations .
Unfortunately,.stigma.and.discrimination.across.the.spectrum.of.HIV.services.remain.major.barriers.to.epidemic.
control ..Many.members.of.key.populations.report.unwelcoming,.disrespectful,.or.discriminatory.treatment.by.
health.workers,.which.affects.whether.those.populations.will.continue.or.seek.HIV.services ..Health.workers’.
emotions.and.biases,.as.well.as.cultural.norms,.beliefs,.and.structural.inequities,.often.determine.how.services.to.
key.populations.are.delivered .
OUR INNOVATION
Through.the.global.USAID-.and.PEPFAR-funded.
LINKAGES.initiative.managed.by.FHI360,.project.partner.
IntraHealth.International.led.the.development.of.the.
Health4All.campaign.in.2016.to.better.assess,.address,.
and.strengthen.the.capacity.of.health.workers.to.serve.
the.needs.of.key.populations ..The.aims.of.Health4All.
are.to.guide.self-reflection.among.health.workers.and.
improve.their.empathic,.clinical,.and.interpersonal.skills.
so.they.can.provide.high-quality,.comprehensive.services.
to.key.populations.free.of.stigma.and.discrimination .
As.part.of.the.campaign,.IntraHealth.produced.a.training.
guide,.Health4All: Training Health Workers for the
Provision of Quality, Stigma-Free HIV Services for Key
Populations ..IntraHealth.pilot-tested.the.guide.in.Angola,.
Malawi,.and.South.Sudan.as.a.working.document.that.
should.be.continuously.refined.through.feedback.from.
ministries.of.health,.trainers,.peer.educators,.and.health.
workers.as.it.adapts.to.local.needs .
Key.to.the.Health4All.approach.is.that.training.is.
conducted.in.collaboration.with.representatives.from.
local.key.population.constituencies.who.are.already.
engaged.in.HIV.programs ..Meaningfully.including.
members.of.key.populations—such.as.those.already.
working.as.advocates.and.program.implementers—in.
the.Health4All.trainings.as.cofacilitators,.participants,.
and.panel.members.is.a.critical.and.essential.component.
of.successful.training.that.leads.to.long-term.changes ..
Honest.dialogue.between.health.workers.and.members.
of.key.population.groups.is.clearly.transformational.
for.many.health.workers ..Another.important.aspect.
of.the.trainings.is.the.use.of.data.from.facilities.to.
guide.participants.to.interpret.and.better.use.available.
monitoring.data.to.assess.quality.and.coverage.of.
services ..
The.training.guide.provides.a.road.map.on.how.to.
assemble.a.facilitation.team;.core.training.principles.to.
ensure.sessions.are.locally.relevant,.self-reflective,.and.
honest;.and.information.about.the.latest.and.best.clinical.
standards.of.care.for.key.populations,.including.World.
Health.Organization.and.United.Nations.HIV.prevention.
strategies ..It.contains.sample.training.agendas.that.can.
be.customized.and.websites.that.connect.to.resources.
and.deeper.information ..
The.training.guide.includes.modules.on.the.rationale.
behind.delivering.services.for.key.populations.and.
the.need.for.high-quality,.appropriate.services ..The.
last.and.most.important.module.helps.ensure.that.
lessons.learned.are.translated.into.action.items.that.
are.required.of.individuals,.communities,.providers,.and.
facilities.to.correct.stigma.and.discrimination ..Action.
plans.generated.from.the.Health4All.trainings.become.
the.responsibility.of.those.in.attendance.as.well.as.
LINKAGES.project.staff.who.monitor.and.support.action.
plans ..
Prior.to.training,.most.health.workers.have.little.or.
no.understanding.of.the.concept.of.key.populations ..
Thoughtfulness.and.empathy.are.elicited.in.health.
workers.over.time.through.a.series.of.questions.such.
as,.“Why.are.key.populations.vulnerable.to.HIV?”.
Participants.learn.the.difference.between.gender.and.
sex.and.how.to.better.understand.those.who.do.not.
adhere.to.cultural.gender.norms,.or.the.reasons.behind.
alcohol.and.drug.abuse ..Participants.gain.an.awareness.
of.human.rights.violations.that.key.populations.often.
Health4All: Strengthening Health Workers’ Capacity to Serve Key Populations with Stigma-Free HIV Services
30
experience,.such.as.rape,.verbal.abuse,.or.being.denied.
food.or.services ..The.training.ends.with.a.follow-up.
questionnaire.to.see.how.well.participants.absorbed.
knowledge .
Complementing the Health4All training
strategy, LINKAGES regularly monitors
the quality of services among its
partners through surveys and helps
them to make changes, as needed, to
modify activities and improve services.
The program has also evolved to focus
more on younger populations and
those who engage in multiple high-risk
behaviors.
WHAT WORKED
Since.2016,.IntraHealth.has.worked.with.14.LINKAGES.
country.offices.in.Africa,.Asia,.and.the.Caribbean.
to.deliver.Health4All.trainings.to.more.than.800.
participants ..IntraHealth.and.LINKAGES.have.
continuously.refined.the.guide.and.strategies.to.
reflect.insights.from.the.trainings ..To.date,.pre-.and.
post-training.assessments.have.consistently.
demonstrated.increases.in.knowledge.and.changes.in.
attitudes.related.to.key.populations .
Post-training.surveys.show.that.those.who.go.through.
the.training.report.that.they.gain.better.insight.into.key.
populations,.the.factors.that.make.them.vulnerable,.the.
challenges.they.face,.and.the.constraints.of.professionals.
in.dealing.with.those.issues ..The.governments.of.
Cambodia,.Indonesia,.Kenya,.and.Suriname.have.adapted.
and.endorsed.Health4All.as.a.national.curriculum ..
WHAT WE LEARNED
It’s.imperative.that.key.populations.are.fully.engaged.in.
the.Health4All.approach,.as.some.of.the.most.important.
outcomes.of.the.trainings.are.the.new.social.connections.
established.among.key.population.advocates,.HIV.
program.administrators,.and.service.providers ..Creating.
training.environments.that.are.safe.spaces.for.open.
and.honest.dialogue.between.health.workers.and.key.
populations.proved.relatively.easy ..Most.participants.
are.respectful.of.one.another ..Health.workers.are.eager.
to.learn.more.about.key.populations,.especially.their.
personal.experiences.trying.to.access.HIV.or.other.health.
care.services ..But,.more.than.that,.health.workers.truly.
want.to.serve.their.clients.as.best.they.can ..
This.training.should.be.delivered.to.anyone.at.a.health.
facility.who.interacts.with.key.populations,.not.just.
clinical.health.workers.but.security.guards,.drivers,.
and.receptionists ..It.is.critical.that.facilities.create.
supportive.environments.that.are.holistically.free.from.
discrimination.and.stigma.so.that.key.populations.will.
feel.encouraged.to.seek.HIV.services.and.treatments,.
thereby.joining.other.populations.who.have.been.able.to.
successfully.manage.the.virus .
NEXT STEPS AND OPPORTUNITIES FOR ADAPTATION AND SCALE-UP
More.program.research.is.needed.to.determine.the.
long-term.effects.of.the.Health4All.approach,.even.as.
it.has.been.recognized.and.scaled.up.as.an.important.
instigator.for.tackling.complex.interrelated.social.
norms.and.attitudes.that.affect.key.populations’.access.
to.and.use.of.HIV.services ..IntraHealth.continues.to.
support.several.LINKAGES.country.programs.in.the.
implementation.of.Health4All,.and.to.make.materials.
available.for.the.global.community.to.adapt.and.tailor.
it.for.further.use ..IntraHealth.has.also.developed.short,.
refresher.education.materials.to.be.used.with.those.
already.trained.in.Heatlh4All.to.support.maintenance.and.
expansion.of.Health4All.campaigns ..
COUNTRIES THAT HAVE COMPLETED HEALTH4ALL TRAININGS
Angola,.Burundi,.Cambodia,.Côte.d’Ivoire,.Democratic.Republic.of.the.Congo,.Haiti,.Honduras,.Indonesia,.Liberia,.
Malawi,.Mali,.Mozambique,.South.Sudan,.Suriname,.Thailand .
31
Published.August.2019
Photos.by.DL.Anderson,.Georgina.Goodwin,.Malaika.Media,.Emily.Nicholson,.Clément.Tardif,.
Tommy.Trenchard,.and.Morgana.Wingard.for.IntraHealth.International
ACKNOWLEDGEMENTS
We.thank.the.following.people.for.their.contributions.to.the.content.of.this.publication:.Allan.Agaba,.Vince.Blaser,.
Melanie.Joiner,.Peter.Milo,.Janet.Muriuki,.David.Nelson,.Emily.Nicholson,.Vincent.Oketcho,.Karah.Pedersen,.Beth.
Rogers.(consultant),.and.Boniface.Sebikali ..The.publication.is.one.output.of.a.landscape.analysis.of.innovation.at.
IntraHealth.commissioned.by.its.chief.technical.officer,.Dai.Hozumi,.and.conducted.in.2019.by.a.team.of.Casey.
Bishopp,.Emily.Nicholson,.and.Molly.Rosett ..Above.all,.we.thank.all.of.the.local.staff,.partners,.and.stakeholders.who.
moved.the.approaches.described.in.this.publication.forward,.and.the.donors.that.supported.the.work,.including.the.
United.States.Agency.for.International.Development,.the.Bill.&.Melinda.Gates.Foundation,.Merck.for.Mothers,.and.the.
Medtronic.Foundation .
6340.Quadrangle.Drive,.Suite.200
Chapel.Hill,.NC.27517
Tel:.(919).313-9100
1100.17th.Street.NW,.Suite.600.
Washington,.DC.20036
Tel:.(202).407-9473
Find.us.on:.www .intrahealth .org
